<html>
<head>
<title>WallyPark Secure Membership Form</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">

<link href="newWallyStylesBlank.css" rel="stylesheet" type="text/css">
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<body>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
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    <td id="tableRightNoCap"><table width="250" border="0" cellpadding="0" cellspacing="0">
                                <form method="post" action="WCapp.pl">
                                  <input type="hidden" name="subject" value="PHL WallyClub Application" />
                                  <input type="hidden" name="recipient" value="apanter@wallypark.com" />
                                  <input type="hidden" name="redirect" value="appResponse.html" target="_blank"/>
                                  <input type="hidden" name="required" value="Name:,E-mail:" />
                                  <tr>
                                    <td width="170" height="22" valign="middle" class="forms">Name: <strong><font color="#FF0000">*</font></strong></td>
                                  </tr>
                                  <tr>
                                    <td>                                      <input name="Name:" type="text" style="width:200px;color:#333333;background-color:#cccccc;font:11px Verdana,Helvetica" size="30" maxlength="100" />                                    </td>
                                  </tr>
                                  <tr>
                                    <td height="22" valign="middle" class="forms">Company:</td>
                                  </tr>
                                  <tr>
                                    <td height="11" valign="middle">                                      <input name="Company:" type="text" style="width:200px;color:#333333;background-color:#cccccc;font:11px Verdana,Helvetica" size="30" maxlength="100" />                                    </td>
                                  </tr>
                                  <tr>
                                    <td height="22" valign="middle" class="forms">Address:</td>
                                  </tr>
                                  <tr>
                                    <td height="22" valign="middle">                                      <input name="Address:" type="text" style="width:200px;color:#333333;background-color:#cccccc;font:11px Verdana,Helvetica" size="30" maxlength="100" />                                    </td>
                                  </tr>
                                  <tr>
                                    <td height="10" valign="middle"><img src="images/spacer.gif" width="1" height="1"></td>
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                                    <td height="22" valign="middle"><table width="100%" border="0" cellpadding="0" cellspacing="0">
                                      <tr>
                                        <td height="22" class="forms">City:</td>
                                        <td class="forms">State:</td>
                                      </tr>
                                      <tr>
                                        <td><input name="City:" type="text" style="width:120px;color:#333333;background-color:#cccccc;font:11px Verdana,Helvetica" size="30" maxlength="100" /></td>
                                        <td><select name="fiftyStatesAbb">
  <option value="" selected>- State -</option>
  <option value="AK">AK</option>
  <option value="AL">AL</option>
  <option value="AR">AR</option>
  <option value="AZ">AZ</option>
  <option value="CA">CA</option>
  <option value="CO">CO</option>
  <option value="CT">CT</option>
  <option value="DE">DE</option>
  <option value="FL">FL</option>
  <option value="GA">GA</option>
  <option value="HI">HI</option>
  <option value="IA">IA</option>
  <option value="ID">ID</option>
  <option value="IL">IL</option>
  <option value="IN">IN</option>
  <option value="KS">KS</option>
  <option value="KY">KY</option>
  <option value="LA">LA</option>
  <option value="MA">MA</option>
  <option value="MD">MD</option>
  <option value="ME">ME</option>
  <option value="MI">MI</option>
  <option value="MN">MN</option>
  <option value="MO">MO</option>
  <option value="MS">MS</option>
  <option value="MT">MT</option>
  <option value="NC">NC</option>
  <option value="ND">ND</option>
  <option value="NE">NE</option>
  <option value="NH">NH</option>
  <option value="NJ">NJ</option>
  <option value="NM">NM</option>
  <option value="NV">NV</option>
  <option value="NY">NY</option>
  <option value="OH">OH</option>
  <option value="OK">OK</option>
  <option value="OR">OR</option>
  <option value="PA">PA</option>
  <option value="RI">RI</option>
  <option value="SC">SC</option>
  <option value="SD">SD</option>
  <option value="TN">TN</option>
  <option value="TX">TX</option>
  <option value="UT">UT</option>
  <option value="VA">VA</option>
  <option value="VT">VT</option>
  <option value="WA">WA</option>
  <option value="WI">WI</option>
  <option value="WV">WV</option>
  <option value="WY">WY</option>
</select></td>
                                      </tr>
                                    </table>                                      </td>
                                  </tr>
                                  <tr>
                                    <td height="22" valign="middle" class="forms">Zip:</td>
                                  </tr>
                                  <tr>
                                    <td height="22" valign="middle"><input name="Zip Code:" type="text" style="width:90px;color:#333333;background-color:#cccccc;font:11px Verdana,Helvetica" size="30" maxlength="100" /></td>
                                  </tr>
                                  <tr>
                                    <td height="22" valign="middle" class="forms">Phone:</td>
                                  </tr>
                                  <tr>
                                    <td height="22" valign="middle"><input name="Phone:" type="text" style="width:200px;color:#333333;background-color:#cccccc;font:11px Verdana,Helvetica" size="30" maxlength="100" /></td>
                                  </tr>
                                  <tr>
                                    <td height="22" valign="middle" class="forms">Fax:</td>
                                  </tr>
                                  <tr>
                                    <td height="22" valign="middle"><input name="FAX:" type="text" style="width:200px;color:#333333;background-color:#cccccc;font:11px Verdana,Helvetica" size="30" maxlength="100" /></td>
                                  </tr>
                                  <tr>
                                    <td height="22" valign="middle" class="forms">Email Address: <strong><font color="#FF0000">*</font></strong></td>
                                  </tr>
                                  <tr>
                                    <td height="22" valign="middle"><input name="E-mail:" type="text" style="width:200px;color:#333333;background-color:#cccccc;font:11px Verdana,Helvetica" size="30" maxlength="100" /></td>
                                  </tr>
                                  
                                  <tr>
                                    <td>&nbsp;</td>
                                  </tr>
                                  
                                  <tr>
                                    <td height="15" class="forms"><strong><strong><font color="#FF0000">*</font></strong> NAME and EMAIL  are required fields.</strong></td>
                                  </tr>
                                  <tr align="center">
                                    <td height="4"><img src="images/spacer.gif" width="1" height="1" /></td>
                                  </tr>
                                  <tr align="center">
                                    <td width="170">                                      <input type="submit" value="Submit Info" name="submit" />                                    </td>
                                  </tr>
                                </form>
      </table>
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